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Reporting Health Care Fraud & Abuse

Appeal FormPDF File
See also How to Appeal

File an External Review - South Dakota Division of InsuranceExternal Site

Authorization for Disclosure to Housing AuthorityPDF File
This form is used to authorize Wellmark to disclosure premium information to a housing authority at the request of the individual.

Authorization to Use or Disclose Protected Health InformationPDF File
This form is used to authorize Wellmark to release protected health information to an individual or entity other than yourself.

Personal Representative Appointment and Authorization to Release Protected Health InformationPDF File
This form is used to appoint someone to act on your behalf, as well as to authorize Wellmark to release protected health information to them.